Mealtime Anxiety & Sensory Processing in Pediatric Feeding

This post is from Irish feeding clinician and researcher, Hazel Wolstenholme PhD

It is very common to hear concerns like, “my child gags a lot when he’s eating”; “she can’t stand the smell when I’m cooking”; “he has difficulty with smooth or creamy textures”; or “they constantly fidget and can’t sit still at the table.” As a feeding professional, it can be tricky to tease out whether these behaviors relate to sensory processing challenges or anxiety (or both!). Why? Because anxiety and sensory processing are highly related.

Anxiety and Sensory Processing Can Impact Eating

In response to a perceived threat or danger, one of the initial tasks of the nervous system is to interpret incoming sensory information so that the nervous system can respond to the threat (as part of the fight-flight response) (Perry, 1998). Over time, the nervous system learns, and in response to continued, or toxic stressors, can become either hypervigilant and overly sensitive, or at times, dissociative (described by some as “numb” or “zoned out”) (Perry, 1998).

The relationship between anxiety and sensory processing difficulties goes both ways. Early life trauma and stress can contribute to the development of sensory processing difficulties (Hambrick, Brawner and Perry, 2019). Multiple theories have been proposed, suggesting that anxiety may cause sensory over-responsivity, that sensory over-responsivity may cause increased anxiety, and that a combination of genetic and environmental factors may contribute to the co-occurrence of both anxiety and sensory sensitivity (Green & Ben-Sasson, 2010).

And autistic adults have shared how dysregulating and traumatizing it felt to be trapped in sensory overwhelm with no escape, often for most of a school day. The anticipatory anxiety around these experiences compounded the misery.

When a child is in a state of anxiety, they are more easily threatened or startled by stimuli that may not otherwise be perceived as a threat (Perry, 1998). So, it makes sense that when a child is feeling anxious about mealtimes, that they will be hypervigilant and more sensitive to (have a lower threshold for) sensory information (like smells, textures and sounds). They may also be more likely to perceive stimuli or requests (like being prompted to taste something) as a threat, leading to further anxiety which can have a negative impact on digestion and appetite.

What Does the Feeding Research Say?

A study of 95 children aged 5-10 years (Farrow & Coulthard, 2012) found that both anxiety and sensory sensitivity were associated with selective eating. Interestingly, they found that sensory sensitivity explains why children with higher anxiety are more likely to be selective about their food intake. These findings were replicated in a later study (Zickgraf & Elkins, 2018) of 158 children aged 8-17 and 813 young adults, and were upheld in a sample of children with obsessive-compulsive-spectrum and anxiety disorders.

Putting it into Practice

Of course, there are children who need extra support with sensory processing, and in these cases, children should be referred to an Occupational Therapist experienced in this area. Considering whether a child presents with sensory processing challenges or anxiety in other situations outside of mealtimes can also provide clues about what may be underlying their eating difficulties.

But – what happens if we focus on reducing mealtime stress, anxiety and pressure first? If mealtimes are less stressful and perceived by the child as a non-threatening environment (felt-safety), it is easier for children to process sensory information optimally and to be more comfortable participating in the meal. Then it is possible to see the child’s capabilities for what they are, without them being clouded by mealtime stress and anxiety.

What Does this Look Like?

When we lower mealtime anxiety and help children to feel safe, secure, and not under pressure at mealtimes, we often start to notice improvements in behaviors that look solely like sensory processing challenges.

When children’s accepted foods are planned into the meal, when they are not prompted or pressured to eat any other family foods served, and when children are reassured that they can eat as much or as little as they like, children’s anxiety starts to reduce. At this point, parents have shared examples with me such as:

“He doesn’t seem so bothered by the smell when I’m cooking meat anymore.”
“She couldn’t sit still before – but her need to get up and down from the table seems to be reducing.”
“Gagging at mealtimes is almost non-existent now – we haven’t noticed it for a while.”

This reduced anxiety and increased comfort at mealtimes paves the way for the child’s confidence (RFT value of competence) and curiosity (RFT value of intrinsic motivation) with eating to grow.

The take-home message?

Anxiety and sensory processing at mealtimes are highly related and tricky to pick apart. If we focus on reducing mealtime anxiety first, it is then easier to determine how a child is coping with sensory information at mealtimes in their relaxed state.

Surprisingly (or not?), as mealtime anxiety reduces in those first few weeks of responsive feeding, many parents report that their concerns (like gagging, constant fidgeting/leaving the table, and negative responses to food smells) start to resolve without us doing anything to target those behaviours directly.

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